ARDS Case Study

ANSWERS

A 60-year-old man went to the emergency room complaining of right-sided chest pain and coughing. The pleuritic chest pain had been present for the previous month. The associated cough produced yellow sputum but no hemoptysis. He had unintentionally lost approximately 30 pounds in the previous six months and was experiencing nightly sweats. He had denied experiencing fevers, chills, myalgias, or vomiting. He also denied having any sick contacts or having traveled recently. He recalled childhood exposures to tuberculosis patients.

The patient had smoked one pack of cigarettes per day for 50 years and denied using recreational drugs. He claimed to consume twelve beers per day and to have suffered from delirium tremens, slight right-sided rib fractures, and a wrist fracture due to his alcohol consumption. He had previously worked in steel mills but had left a few years before. He collected coins and used mercury to clean them.

 

The patient’s previous medical history was notable for chronic “shakes” of the upper extremities, and he had not sought medical attention. He did not take any regular medications other than daily multivitamin tablets.

Hospital training

He was initially admitted to the general medical floor for treatment of community-acquired pneumonia and to prevent delirium tremens (see Figure 1). He began treatment with ceftriaxone, azithromycin, thiamine, and folic acid. The Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWAS-Ar), a measure of withdrawal severity, was used to initiate and titrate diazepam (1). By hospital day 5, his respiratory status had deteriorated to the point where he needed to be transferred to the intensive care unit (ICU) for hypoxemic respiratory failure. Despite receiving increased benzodiazepine doses, his neurologic status had deteriorated significantly, with worsening confusion, memory loss, drowsiness, visual hallucinations (patient began seeing worms), and worsening upper extremity tremors without generalized tremulousness.

 

Physical Examination

When the patient arrived at the Medical ICU, he was cachectic and dyspneic. He could not finish sentences. His blood pressure was 125/71 mm Hg, his heart rate was 122/min, his temperature was 100 °F, his respiratory rate was 33/min, and his oxygen saturation was 77% with room air and 92% with a 40% venti-mask. He had an oxygen saturation of 92% on room air when he arrived at the hospital. The heart exam revealed tachycardia but regular rhythm, normal S1 and S2 intervals, and no murmurs, gallops, or rubs. On auscultation of the lung fields, breath sounds were reduced on the right side in the upper zone, with no adventitious sounds present. The abdomen was free of organomegaly. The extremities of the patient were normal, with no clubbing or edema. He was only concerned with people and could not pay attention or recall recent events. He moved all four limbs with slightly brisk deep tendon reflexes. The neck was flexible, and the pupils responded quickly to light.

Lab

The white blood cell count in mm3 was 11,000, with 38% neutrophils, 8% lymphocytes, 18% monocytes, and 35% bands.

 

33% Hematocrit

 

Platelets were 187,000/mm3.

 

The serum sodium concentration was 125 mmol/L, the potassium concentration was three mmol/L, the chloride concentration was 91 mmol/L, the bicarbonate concentration was 21 mmol/L, the blood urea nitrogen concentration was 14 mg/dl, the serum creatinine concentration was 0.6 mg/dl, and the anion gap was 14.

 

The urine sodium level is ten mmol/L, and the urine osmolality is 630 mosm/kg.

 

Albumin was 2.1, total protein was 4.6, total bilirubin was normal, aspartate transaminase (AST) was 49, alanine transaminase (ALT) was 19, and alkaline phosphatase was 47.

 

Acid-fast bacilli were not found in three sputum samples (AFB).

 

Bronchoalveolar lavage (BAL) white blood cell count was 28 cells/l, red blood cell count was 51 cells/l, AFB was negative, and Legionella culture was negative. The BAL gram stain revealed no organisms or polymorphonuclear leukocytes.

 

Blood cultures for growth were negative.

 

Pasteurella multocida grew moderately in sputum cultures.

 

The heart’s 2D transthoracic ECHO revealed standard valves, an ejection fraction of 65%, normal left ventricular end-diastolic pressure, and normal left atrial size. There was no vegetation found.

 

At 72 hours after placement, the purified protein derivative (PPD) administered via Mantoux testing was 8 mm in size.

 

Serology for the human immunodeficiency virus (HIV) was negative.

 

On presentation to the ICU, an arterial blood gas (ABG) analysis was performed on room air: pH 7.49, PaCO2 29 mm Hg, and PaO2 49 mm Hg.

QUESTION

ARDS Case Study

Please provide complete, thorough, and detailed answers to all questions in the case study attached. Multiple choice answers should include the correct choice and rationale for that choice and/or rationale why other choices are incorrect.

Please see attached document.